EVALUATION OF ANTIRETROVIRAL THERAPY FOLLOWED BY AN EDUCATIONAL INTERVENTION TO INCREASE APPROPRIATE USE IN ZIMBABWE

SETTINGS AND PROBLEM Zimbabwe - one of the world’s highest HIV infection rate. Late 1990s: Antiretroviral Therapy (ARVT) used in private sector with varying standards. ARVT = narrow therapeutic index Potential problems: Sub-therapeutic effects, viral resistance  treatment failure, Length of desired outcomes in individual patient is reduced Efficacy of ARVs within the population is reduced Unnecessary toxicity, Wastage of limited financial resources Disadvantage to surviving family members

OBJECTIVES Examine standards of ARVT in the private health sector by investigating: initiation, monitoring and evaluation of ARVT, relevant patient outcomes To design and pilot-test an educational intervention promoting the rational use of ARVs by increasing the physician’s knowledge on rational use of ARVs

METHODS Setting: Private health sector physicians in urban centers in Zimbabwe. Study 1: Design: Retrospective medical record review. Individual patient data were collected on: patients’ assessment prior to starting ART; prescribing patterns; monitoring for efficacy/safety; and clinical/virological outcomes. Study 2: Design: Educational intervention with pre- and post intervention assessment (MCQs) Intervention: Academic detailing combined with distribution of concise printed materials

CLINICAL EVALUATION BEFORE STARTING ARVT Important observations: Only 18% patients received full clinical evaluation as recommended by current clinical guidelines 41% had no records of any clinical examination Complete laboratory examinations incl. CD4, TLC, VL, LFT, FBC was performed in only 2 patients (6%)

INITIAL & CURRENT ARVT

PRESCRIBING OF ARVs Incorrect dose of ARVs in total of 15 patients (38%), AZT (67% of effective dose prescribed ), 7 pts. underdosing of SQV (22% of effective dose prescribed); 2pt. Double dose of DDI Interactions: co-administration of Indinavir and Rifampicin Irrational first-line therapy i.e. Didanosine + hydroxyurea combination Irrational sequencing i.e. Patients were frequently switched from triple to dual then monotherapy DDI+ HYU was the current therapy for 7 pts. (18%)

CLINICAL & IMMUNOLOGICAL OUTCOMES Important observations: Desired outcomes were found in pts. on triple ARV regimens; 16 patients (41%) undetectable VL, high CD4 and clinically well) Dual or monotherapy often resulted in poor outcomes in majority of pts 23 (59%) High viral load, CD4 count <350cells/mm3 Clinically unwell with OIs

EDUCATIONAL INTERVENTION Structured academic detailing was developed delivering key messages regarding: Choices for ARVT and potential drug interactions Monitoring adherence and side effects, When to change therapy Use of hydroxyurea in ARVT Use of antiretrovirals for PMTCT Single face-to-face academic detailing session were delivered to 15 physicians and lasted approx. 30 to 90 min. Printed educational material were handed out to re-inforce key messages Average 27% increase in knowledge of physicians measured by pre - and post assessment. Highest increases were found in knowledge on drug interactions and adverse effects of ARVT.

SUMMARY & RECOMMENDATIONS Irrational choices for ARVT, poor monitoring and evaluation resulted in poor outcomes. High cost of the therapy + poorly informed physicians/patients = irrational choices. Comprehensive training of prescribers is needed to achieve: maximum possible benefits minimising of risks from ARVT and getting the best value (cost-effectiveness). Trained pharmacists providing locally developed and focused information can be valuable resource in prescriber’s education. Reduction in prices of ARVs and necessary tests in private sector is needed to increase affordability and rational use.